Minimal sedation Druginduced state during which patients respond normally to drug verbal commands Moderate sedationanalgesiaconscious sedation ID: 1048408
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1. Good morning
2. GENERAL ANESTHESIA
3. Minimal sedation ‘Drug-induced state during which patients respond normally to drug verbal commands’.Moderate sedation/analgesia/conscious sedation ‘Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation’.3Definition
4. Deep Sedation/ analgesia ‘Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation’.General anesthesia Controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including the inability to maintain an airway independently and respond purposefully to stimulation or verbal command.4
5. Hypnosis -Analgesia-Relaxation-General anaesthesia = Hypnosis + Analgesia + RelaxationA controlled reversible state of:Amnesia AnalgesiaAkinesia Autonomic and sensory reflex blockadeThese are called the “4 A’s” of General Anaesthesia5
6. They did it for a better tomorrow!!!!!6
7. Original discoverer of general anesthetics Crawford Long, Physician from Georgia:1842, ETHER ANESTHESIANitrous oxide - Horace Wells(1845)Chloroform - James Simpson (1847)1929 - Cyclopropane 1935- Thiopentone, 1st IV anesthetic agent1956 - Halothane 7
8. 8Indications of GA
9. 9Contra indications of GA
10. ASA CATEGORY DEFINITIONASA IA normal healthy patient with localized pathology & not systemicASA II Mild systemic disease Eg- Epileptic children on medication Asthmatic ASA IIISevere systemic disease Eg- Congenital heart disease Uncontrolled diabeticASA IVSevere systemic disease that is a constant threat to life Eg- Unstable angina, Symptomatic COPD, Hepatorenal failure10(ASA) physical status classification system
11. ASA CATEGORY DEFINITIONASA VMoribund patient who is not expected to survive without the operation Eg- Not expected to survive > 24 hours without surgery, Multiorgan failure, Hemodynamic instability, Poorly controlled coagulopathyASA VIDeclared brain-dead patient whose organs are being removed for donor purposesASA EAny surgery taken as emergency procedure11
12. 12Types of anesthesia
13. Out-patient short case dental chair anaesthesiaASA class I & II Rapid induction & early recoveryAnaesthesia induction: Anesthesia is maintained by anesthetic vapour. Eg – sevoflurane, carried in a mixture of oxygen & nitrous oxideOropharynx - packed with gauze to protect airway.13
14. Nnnn14Pulse oximeterBlood pressure cuffECG
15. Out-patient / day-stay intubation anaesthesiaASA class I or II15
16. 16Short acting neuro-muscular paralysis agent Several hours for child to recoverAnaesthesia induction :
17. In-patient / hospital-stay intubation anaesthesiaASA class IIIUnfit for short or medium length17
18. 18Classification
19. Capable of producing analgesiaReversible & controlled level of consciousnessNot have any cytotoxicitySafeInduction of anesthesia should be smoothRecovery of anesthesia should be quickDrug must quickly metabolized & excretedShould not interfere with cardiovascular & respiratory functionsProvide complete muscle relaxation19Requirements of ideal general anesthetic agents
20. lorazepam & diazepam20Class:BenzodiazepineAction:Anxiolysis, Sedation, Amnesia Contraindications:Hypersensitivity to benzodiazepinesAcute narrow angle glaucomaPregnancyCommon side effects:Respiratory depressionHypotensionConfusion/disorientationNauseaRecommended for:Minor invasive procedures Anxiety reliefReversal agent:Flumazenil
21. KETAMINE21ClassDissociative anestheticAction:Anesthesia, Sedation, Amnesia, AnalgesiaContraindications:Infants ≤ 3 months (higher risk of airway complications)Head injuryThyroid diseaseSignificant eye injury and/or disease Common side effects:LaryngospasmIncreased salivation Hypertension/tachycardiaNausea & vomitingRecommended for:Hard-to-handle patients (e.g., Developmentally delayed)Painful procedures (e.g., Burn debridement, Orthopedic, Foreign body removal)
22. NITROUS OXIDE22Class:Anesthetic (blended with 50 – 70% O2)Action:Amnesia, Analgesia, AnxiolysisContraindications:Some chronic obstructive pulmonary diseases Small bowel obstructionPneumothoraxCommon side effects:Respiratory depression Dizziness & headacheDisorientationNausea & vomitingRecommended for:Moderately painful proceduresWidely used to reduce anxiety during dental procedures
23. Parental awarenessObtaining anesthetist fitness & parental consentPre anaesthetic instructionsPre anaesthetic medication23Pre- Anaesthetic schedule
24. Parental awareness Obtaining anesthetist fitness & parental consentPre – Anesthetic evaluation Purpose To obtain pertinent information about the patients medical history and physical as well as mental condition.To determine the need for a medical consultation and the kind of investigations required.To choose the anesthesia plan to be followed, guided by the risk factors, uncovered by the medical history.24
25. Selection of patient ASA I & ASA IIASA III & ASA IV – Require consultationClinician administrating anesthesia: Abnormalities of the major organ systems25
26. Patients presenting for sedation/analgesia should undergo a focused physical examinationVITAL SIGNS AT VARIOUS AGES26AGEHEART RATEBeats/minBLOOD PRESSURE mm/HgRESP . RATEBreaths/min1-370-11090-105 / 55-7020-303-665-11095-110 / 60-7520-256-1260-95100-120 / 60-7514-221255-85110-135 /65-8512-18
27. Airway Assessment Procedures for Sedation and Analgesia Factors that may be associated with difficulty in airway management areHistory Previous problems with anesthesia or sedationStridorPhysical Examination27
28. Head and NeckShort neck, Limited neck extension, Neck mass, Cervical spine disease or trauma, Tracheal deviation.MouthSmall opening , protruding incisors, loose teeth , dental appliances, tonsillar hypertrophy, nonvisible uvula.JawTrismus, Significant malocclusion28
29. Mallampati classification29significance Used to predict the ease of endo tracheal intubation. High score iii & iv – difficult in intubation & higher incidence of sleep apnea.
30. Thyro-mental distanceIt is measured from the thyroid notch to the tip of the jaw with the head extended.Used to predict the difficulty of intubation30
31. Process of providing the patient or the parent with relevant information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made by the patient. 31Informed consent form
32. 1.Legal name and date of birth of pediatric patient. 2. Legal name and relationship to the pediatric patient/ legal basis on which the person is consenting on behalf of the patient. 3. Patient’s diagnosis. 4. Nature and purpose of the proposed treatment in simple terms. 5. Potential benefits and risks associated with that treatment. 6. Place for parent to indicate that all questions have been asked and adequately answered. 7. Places for signatures of the parent or legal guardian, dentist, and an office staff member as a witness.32
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34. Pre-medicationObjectives of pre-medicationReduce anxiety and fear.Reduce secretions Enhance the hypnotic effect of GA agents.Reduce post op nausea and vomitingProduce amnesia.Reduce the volume and pH of gastric contentsAttenuate vagal reflexesAttenuate sympatho adrenal responses.34
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36. DRUGROUTEDOSAGEACTIONTRADE NAMENEUROLEPTICS-ChlorpromazineIM25mgAlley anxiety and smooth inductionTHORAZINEH2 BLOCKERS-RanitidineORAL120mgReduces ph of gastric juiceACIDOMANTI-EMETICS-MetachlopromideIM10-20mgReduces post operative vomitingMETPARANTI-CHOLINERGICS-AtropineIV/IM0.01-0.02mg/kgReduces secretionsATROPEN36
37. 37Pre anaesthetic instructions
38. 38Stages of anesthesia
39. Emergency equipment for sedation and analgesia Basic airway management equipmentSource of compressed oxygen (tank with regulator or pipeline supply with flow meter)Source of suctionSuction catheters Face masks Self-inflating breathing bag-valve set Oral and nasal airways Lubricant39
40. Pharmacologic AntagonistsNaloxoneFlumazenilEmergency medications40Category DrugDosage IndicationsAntihistaminesBenadryl 10-50 mg Mild allergic reactionschlortrimeton10mgBarbiturates Nembutal 50-100mgToxic overdoseSeconal 50-100mg
41. Category DrugDosage IndicationsSteroids Solu- Cortef100mgSevere allergic reactionsDecadron 4-8mgvasopressorsMethedrine 10-20mgHypotension Vasoxyl 10-20mg Bronchodilators Isuprel 0.2 mg Asthamatic conditions Aminophylline 0.25- 0.5 gm41
42. DrugDosage IndicationsEpinephrine 0.5-1mgAnaphylactic shock Nitroglycerin 0.3-0.6mg sublinguallyAngina pectoris Atropine sulfate 0.4- 0.6 mg Bradycardia Succinyl choline 40-60mg Laryngospasm42
43. Necessary instrument - Atleast two setsEquipment – Tested prior to use43
44. anesthesia machine44
45. Breathing systemComponents that connect the patient to the anaesthetic machineAdjustable pressure limitingReservoir bagInspiratory limbExpiratory limbLength varies depending on the system in use Diameter Standard size 22mm - Adult Paediatric systems – 18mm45
46. MASKAllows administration of gases from the breathing system, without introducing any invasive apparatus into the patients airway.Parts46 SizeUse0Infant1Small Child2Child3Small Adult4Adult5Large Adult
47. Types47Anatomical maskRendell-baker-soucek maskEndoscopic mask
48. Techniques for placement48One Hand MethodTwo Handed Method
49. LARYNGOSCOPEA laryngoscope is an instrument used to view larynx and adjacent structures, most commonly for introducing tube into the trachea 49
50. Endotracheal tubePlacement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugsTypes Oral or nasal, Cuffed or uncuffed, Double-lumen endobronchial tubes Laser resistant tubes50
51. Sizing(Diameter )Neonate - 3.0 mm 0-6 months -3.5mm 6-12 months -4.0 mm LENGTHVisualize the tube passing through vocal cords Inserted upto black markEndotracheal intubation should take no longer than 30 seconds51
52. IndicationsSurgical procedures in which it is not feasible to administer anesthetic gases via mask.Long procedures Procedures in which there are chances of having blood, secretions, pus, vomitus in the oral cavity.ContraindicationsAny situation where the pharynx is obstructed (pharyngeal foreign body, massive swelling of the pharynx)52
53. Nasotracheal intubationNasotracheal intubation is an established airway management technique in patients undergoing throat and oral surgery.Indications Angioedema of the tongue.Mechanical obstructions to mouth opening from mandibular fixation or other oral pathology.Limited mouth opening.53
54. Contra-indicationsSiginificant hypoxia.Base of skull fracture.Disruption of the midface, nasopharynx or roof of the mouth.ComplicationsMild, moderate, or severe nasal bleeding. Retropharyngeal perforation.54
55. Retropharyngeal abscess (considered an infectious disease – Emergency condition) Complications Upper airway obstructionAspiration of purulent material if the abscess rupturesSpread to the posterior mediastinumMeningitisVascular erosion.The disorder must be recognized quickly, antibiotic therapy must be initiated rapidly, and surgical drainage may be necessary for a successful outcome. 55
56. Airway Oral airway or Guedel pattern airway Types Oropharyngeal airway Naso pharyngeal air way56
57. InsertionPre-lubricate with either the patient's own saliva or a small amount of lubricating jelly.Concave side up; pass to the back of the hard palate, then rotate 180o to concave side down57
58. Nasopharyngeal airway Indications Patients with loose teeth Trauma case Inability to open mouth Any pathology of oral cavity.ContraindicationsHemorrhagic disorders Nasal deformity On anticoagulants.58
59. Laryngeal mask airwayMany centers now prefer to insert LMABoat shape mask Provide: Good protection against aspiration of blood or saline or any dental debrisBeing increasingly used in childrenLess invasive when compared to endotracheal intubation and causes less discomfort.59
60. Monitoring and documentationElectrocardiography (ECG)Placement of electrodes which monitor heart rate and rhythm.Help the anaesthetist to identify early signs of dysrhythmias, myocardial ischemia, electrolyte abnormalities.Detect 95% of intra operative ischemia, allowing for early intervention60
61. Pulse oximetry Adequate oxygenation of tissues occurs above 95% - lower than this considered to be hypoxemic Normal circumstances child oxygen saturation is 97-100% Early detection of hypoxia – decreases the likelihood of adverse out comes like cardiac arrest & death61
62. CAPNOMETERRate & depth of respiration. Measures the amount of carbon dioxide expired by the patient's lungs. Allows the anaesthetist to assess the adequacy of ventilation. Respiratory rate - children 12-18/min62
63. DOCUMENTATION OF MONITERED PARAMETERSPatient vital signs – 5min interval Should be recorded before initiating analgesia, after administration of medications, regular intervals during procedure, upon initiation of recovery, immediately before dischargeTime oriented anesthetic record must be maintained 63
64. Extubation The discontinuation of the airway is often based on the assessment of pulmonary mechanics. Guidelines of adequate pulmonary mechanical function: Respiratory rate less than 25 breaths per minute Spontaneous tidal volume greater than 5 ml/kg Inspiratory force of at least –20 cm H2O Vital capacity at least 10 ml/kg64
65. Guidelines for extubation Extubation should take place during a period of the day when adequate physician, nursing and therapist staffs are readily available. Monitoring and continuous evaluation of the patient is necessaryPrior to extubation, all of the equipment necessary for reintubation should be available at the bedside in case of acute decompensation. Racemic epinephrine should be available for aerosolization in case of acute airway edema after extubation.65
66. Complications at extubationDifficult extubationTracheal collapse. Airway obstruction.Aspiration of stomach contents66
67. Throat packsThroat packs are often inserted by anaesthetistsAbsorb material created by surgery in the mouthPrevent fluids or material from entering the oesophagus or lungsPrevent escape of gases from around tracheal tubesStabilize artificial airways.67
68. 68Recovery positionThree-quarters prone position of the bodyDesigned to prevent suffocation through obstruction of the airway, which can occur in unconscious supine patients
69. ComplicationsEmergence delirium- post anesthetic excitementChildren are more prone to disorientation, hallucinations and uncontrolled physical activity during emergence from general anaesthesia69
70. Postoperative hypoxaemiaCause Intubation,Use of muscle relaxants, intravenous induction and duration of anaesthesia more than 1 hour is associated with higher incidence of hypoxaemia.ManagementAdministration of 100% oxygen at the end of anaesthesia.70
71. Complications associated with intubationSore throat Cause:Laryngoscopy & endotracheal intubation. Use of dry anaesthetic gasesManagement:Steam inhalation, cough lozenges and analgesics provide good relief71
72. Laryngospasm Patient makes croaking sound during inspiration Cause:Reflex response to intubation.Saliva, blood, gastric contents contact with glottic structures.Management:Extubate under deep level of anesthesia CoughingIrritation by artificial airways, secretions, blood and regurgitated gastric material Administer muscle relaxants72
73. CyanosisCause:Misplaced ETT.Airway obstruction.Oxygen supply failureManagement:Increase inspired oxygenCheck gas floe settingsCheck pulse73
74. Protocol for dischargeRequirement that patients drink clear fluids without vomiting before dischargeRequirement of a minimum mandatory stay in recoveryCheck vital signs every 15 min Maintain hemostasis if necessaryMedication for infection , pain, temperature and nauseaEncourage fluidsDischarge the patient care of responsible person after patient has held fluids for 1hr without nausea & vomiting Schedule follow up appointment in 1 week74
75. Post operative instructions for pediatric dentistryAnesthesia can cause dizzy spells for 24 hours.Rest at home the evening of surgery & play inside with toys that cannot harm. Do not let them : Climb stairs, use knives, operate appliances that require concentration.He may return to normal activities the day after surgery.Anesthesia may cause nausea & decreased apatite.Offer patient clear fluids. The morning after surgery he should resume with regular diet.75
76. Suggested books to read:Ferretti GA. Hospital pediatric dentistry and general anesthesia. Wei S H Y. Pediatric dentistry total patient care. Lea & Febiger:Philadelphia;1988: Pg 388-407.Welbury R, Duggal M, Hosey MT. General anesthesia . Paediatric dentistry. 3rd ed. Oxford : New york; 2005: Pg 85-8.Green field W. General anesthesia . Laskin D M. Oral and maxillofacial surgery. 1st ed. CV Mosby company: USA;1992: Pg 659- 691.Damle S G. Text book of pediatric dentistry. 4th ed. Arya medi publishing house PVT LTD : New delhi; 710- 37.Kapoor V. Text book of oral and maxillofacial surgery .1st ed. Arya medi publishing house : New delhi; 1999: Pg 400-576
77. Chockalingam PR. Pharmacological behaviour management. Illustrated paediatric dentistry. 1st ed. Wolters kluwer: New delhi; 2014: Pg 78-85.ASA PHYSICAL STATUS CLASSIFICATION SYSTEM.Last approved by the ASA House of Delegates on October 15, 2014. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system# 77
78. 78Thank you